THE WHITE HOUSE
Office of the Press Secretary
For Immediate Release October 27, 1993
Chapter 7 -- QUALITY
"I am a first grade teacher in a very poor neighborhood in North Philadelphia...Many of [my students] have never seen a family physician; many have never even been inside a public health clinic. I was shocked to find that eight out of ten of their absence notes are written by doctors in the emergency room of nearby hospitals...I feel bad for my students who have never had an ounce of preventive medicine, but I feel angry, as do many of my middle-income peers, who are ultimately footing the bill for the emergency treatment these children are driven to."
In many parts of our nation, for many patients, the quality of health care is unparalleled anywhere in the world. The United States boasts the best technology, the most advanced research, and the greatest number of medical breakthroughs of any advanced nation. When it comes to quality, we have a great deal to be proud of. The Health Security Act protects and improves the high standards we have set for American medicine.
But the quality of our health care is uneven, and threatened by serious flaws in the way we measure and report on which health care treatments should be used and which work best. No clear standards define what is the best medical practice; lack of information compromises the care people get; and inadequate attention to preventive care reduces the effectiveness of treatment and services.
The Health Security Act includes specific provisions to make sure that the high-quality health care delivered in some parts of our country spreads to other areas, and becomes the standard nationwide.
This Act takes steps to arm doctors, hospitals, and health plans with the latest information on state-of-the art treatments and their effectiveness, and arm consumers with information to help them compare the quality of plans.
It measures quality and accountability, focusing on results rather than micromanagement and filling out forms.
It increases funding for health care research to keep American health care and technology state-of-the-art; and it improves health and wellness through unprecedented coverage of preventive care and steps to build a better health care workforce.
BETTER INFORMATION FOR JUDGING QUALITY
Without the information they need to reward high-quality plans with their business, consumers are powerless to force health plans to compete.
Researchers and panels of health professionals have developed new ways to measure the results of different treatments and what type of care and treatment works best. A number of medical professional groups have participated in extensive efforts to develop guidelines for effective medical care for specific conditions and illnesses. The Health Security Act will promote greater sharing and use of information, helping more practitioners benefit from the results.
Many programs around the country have begun using the new approaches to quality, building on better and more available information. Business groups are now joining with doctors, hospitals and health plans to publish information about comparative quality and price. In communities from Nashville, Tennessee to Rochester, New York, and in the state of Pennsylvania, major employers, local hospitals and state governments have begun collecting information that allows businesses and consumers to make valid comparisons among hospitals and physicians.
Under the Health Security Act, American consumers will benefit from greater access to information, which in turn will further improve quality. They will exercise not only the right to choose doctors, other health providers and health plans, but also the right to make informed choices based on meaningful information about how health plans, health professionals and hospitals perform.
Annual performance reports provided by health alliances will survey consumers and measure how their health plans, doctors and hospitals perform on a set of four critical indicators:
These information "report cards" will compare health plans and providers, reporting how various plans performed on carefully selected indicators. Researchers know that certain medical indicators provide clues about overall performance: How many children with asthma in this plan ended up in the hospital last year? How many older people who suffered a fall didn't recover their ability to walk? How many patients who suffered heart attacks survived? On the simplest level: How many patients didn't like this plan and chose another?
Performance reports based on these types of indicators will prove valuable to consumers and health professionals. When choosing a plan or providers within a plan, consumers will be able to judge whether they can expect prompt access to treatment, how the care stacks up against competitors, and what other consumers think about the plan. Merely making this information available will force plans and providers to focus on quality.
A reformed health care system that emphasizes accountability can improve the quality of health care, improve safeguards for patients and reduce bureaucratic regulation.
The Health Security Act will replace the outmoded system for measuring quality in practice today, where government bureaucrats and insurance companies second-guess decisions made by doctors and their patients. In its place will be a quality measurement system focusing on results: Was the treatment the right one? Did it achieve the intended effect? What can we learn from the case? Focusing on results will reduce the paperwork and micromanagement that strangle doctors, nurses, hospitals and clinics. It frees health professionals from intrusive insurance companies and bureaucrats, improves morale, and creates an environment that supports what health professionals are there to do -- care for patients.
Under reform, doctors, clinics and hospitals will have to examine ways to make their delivery of care more efficient while improving quality. "Business as usual" will no longer be profitable. Leading hospitals across the country are already moving in this direction. For example, when doctors at the Hospital of Latter Day Saints in Salt Lake City, Utah realized that post-operative wound infections were causing excessive hospital stays, they experimented with changing the timing of administering antibiotics before surgery. Patients got fewer infections, left the hospital earlier, and saved $450,000 in the first year.
INVESTING IN RESEARCH
Under the Health Security Act, there will be significant initiatives to increase research. Advances in medical science, new medications and technology, and innovations in health care delivery will improve the quality of life for all Americans.
Research related to health promotion and prevention of disease will focus on many common illnesses and other priority areas: heart disease, bone and joint disease, Alzheimer's disease, cancer, AIDS, birth defects, mental disorders, substance abuse, nutrition, and health and wellness programs.
Research regarding clinical practice will increase with an emphasis on quality and effectiveness, as well as access and financing. There will be an emphasis on "outcomes research," to help answer questions about what treatment works best for which conditions, so that doctors can provide the highest quality care for their patients. Expanded research will also measure consumer awareness, decision-making and satisfaction so that the best information is made available to the public. This will ensure that people can make well-informed decisions about their health care.
EMPHASIZING PREVENTIVE AND PRIMARY CARE
Prevention is the cornerstone of the Health Security Act. Incentives for patients and doctors alike to use and prescribe preventive methods are woven throughout. From free coverage of a wide range of preventive services to wellness education and increased research funding, the plan offers unprecedented focus on prevention.
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Academic Health Centers
Academic health centers are the sites of the basic research that ushers in modern medical advances -- new treatments and cures for human illnesses. They pioneer advanced techniques and procedures, from heart-lung transplants to laser surgery for brain aneurysms.
Under the Health Security Act, academic health centers will continue to train physicians and provide state-of-the-art care. The Act sets aside a portion of all health insurance premiums specifically for academic health centers. Resources will be channeled to centers by a formula that recognizes each center's contributions to education, research, and patient care.
While most Americans will not obtain regular care at an academic health center, the Health Security Act requires that everyone has access to specialized care if needed.
The comprehensive benefits package includes a broad array of preventive services not covered by the vast majority of insurance plans -- immunizations, mammograms, well-baby care, and other screenings and early detection techniques to solve health problems before they become serious illnesses. The Health Security Act covers a wide range of preventive services with no coinsurance or co-pay, no matter which plan you join.
The Health Security Act will fundamentally restructure incentives in the health care system. For the first time, every doctor, nurse and health provider will know that they can provide the services they believe are necessary -- and know they will be reimbursed.
"The plan recognizes that successful disease prevention and health promotion must address the health plan of both individuals and communities. It provides for universal coverage of clinical preventive services that have been shown to be effective in preventing disease and prolonging life. All these aspects constitute an approach to prevention that is uniquely comprehensive in scope and long overdue."
Roy L. DeHart, MD, MPH
President, American College of Preventive Medicine
As the American health care system has become more complex, specialized, and technical, it has neglected some simpler and, ironically, less costly needs. The cost of treatment for acute illness has soared, but we continue to spend relatively little on preventive and public health services.
Good primary and preventive care is one of medicine's essential responsibilities. Meeting that need represents one of the essential requirements under health care reform. If the American health care system is to provide high-quality care at affordable prices, it must strike a better balance between physicians, nurses and other professionals who take care of basic needs and those who provide the most sophisticated and specialized treatment for serious illness.
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Not all health problems can be addressed by providing individual health care coverage alone. Greater public health strategies are necessary to improve public health awareness, quality of care, and the prevention of future epidemics.
Public health protects communities against infectious diseases, such as tuberculosis and measles, and helps communities discover how to control chronic disease, such as diabetes and heart disease. It also works to protect the environment and educate about health and related issues.
For too long, public health funds have been sapped to pay for individual care. Under the Health Security Act, public health dollars will reach their intended destination -- targeting issues that plague entire populations rather than individuals first. These efforts promise long-term savings in lives and dollars.
Primary care doctors and nurses work on medicine's front line. They diagnose and treat routine medical problems, refer patients when necessary, and coordinate specialist care. Family physicians, general internists and pediatricians are the principal primary care practitioners among physicians, and many women also consistently see obstetricians and gynecologists. Advance-practice nurses and physician's assistants provide essential primary care as well.
But the number of doctors providing basic, routine care has declined and many states have prevented advance-practice nurses and other health professionals from taking on as significant a role as they might.
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A Model for Reform
Chances are that if you live in the Pacific Northwest, and you belong to a health maintenance organization (HMO), you belong to Group Health Cooperative of Puget Sound. Founded in 1947 and located in Seattle, Washington, Group Health is the single largest provider of health care in the Pacific Northwest, serving 500,000 members. It offers convincing proof of the fact that emphasizing primary and preventive care can mean high-quality care, low costs, and satisfied, healthy patients.
Like the Health Security Act, Group Health covers a wide range of preventive services not covered by most insurance plans. Its efforts have brought results. In fact, Group Health formed the basis for a Rand Corporation study that concluded that providing high-quality care can go hand in hand with controlling health care costs. Another important feature of Group Health is its attention to customer satisfaction, which it measures through regular consumer surveys -- much like the surveys proposed in the Health Security Act for all health plans.
For decades federal policy has reinforced the trend away from training primary care doctors and toward training more specialists. Federal funding of graduate medical education averaged $70,000 for each resident in 1992, with nearly all of the money going toward training in hospitals. Little went to other health care institutions in local communities that provide more basic care. Between 1980 and 1993, American hospitals increased the number of residents in training from 82,000 to 97,000, with 94 percent of the new positions devoted to training in specialty fields of medicine.
Health care reform will increase the demand for primary care physicians, nurses and other health professionals, correcting the long-standing incentives that discouraged medical students from becoming family doctors. But change won't happen quickly. To encourage American teaching hospitals to switch some residency positions from specialist to primary care, the federal government must make it more worthwhile to train them.
Consequently, rather than pay for graduate medical education without regard to specialty, public and private investment will redistribute the balance between residency slots devoted to primary care and those devoted to specialty training. Other federal programs, including an expanded National Health Service Corps, will support students studying primary care and locating in underserved areas, such as rural and urban communities. Loan forgiveness programs for medical students who are trained in primary care, and re-training programs for mid-career specialists who want to work as primary care physicians will further boost the number of primary care doctors.
The Health Security Act also proposes several important steps to remove barriers to practice that currently limit the role of advanced-practice nurses. It enables qualified health professionals who participate in health plans to fully use their expertise and ability to provide care. In addition, federal funds will provide additional resources for training nurses, doubling the number of annual graduates. Support will also be provided for training in mental health and substance abuse treatment.